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Current guidelines and Universal Definition of Myocardial Infarction (UDMI) recommend using rising and falling patterns (RP and FP, respectively) of high-sensitive cardiac troponins (hs-cTn) equally to distinguish acute from chronic myocardial injury. Purpose To compare patients with RP and FP and assess the diagnostic performance of the ESC 0/1 and 0/3 hour (h) algorithms using a RP or FP. Methods Prospectively enrolled patients with suspected MI (excluding those with ST-elevation) were stratified according to their troponin deltas. A RP was defined by an elevation and a FP as a decline in hs-cTnI of ≥2 or &amp;gt;6 ng/L between baseline and 1 or 3h later, respectively. All other patients were classified stable. Three independent cardiologists adjudicated the final diagnoses according to the 3rd UDMI. Our primary endpoints were efficacy measures (positive predictive value [PPV] and specificity in % [95% confidence intervals]) of both algorithms. Patients were followed for up to 4 years for a combined endpoint of all-cause death, incident MI, revascularization or cardiac rehospitalization. Results In total, 3,528 patients (age 64.0 (52.0, 74.0), males 64.0%) were included, of those 418 (11.8%) had a FP and 829 (23.5%) a RP. Compared to patients with a RP, those with a FP had similar age (67.0 [55.0, 76.0] vs. 67.0 [56.0, 75.0]), had generally less cardiovascular risk factors and the number of angiographies was lower (39.5% vs. 58.0%), while the number of late-presenters (&amp;gt;6h after symptom onset) was higher (66.4% vs. 48.8%). The prevalence of MI was higher in the RP (22.6% vs 29.1%). The risk of experiencing the combined endpoint was significantly higher for both, FP and RP, with a greater risk for a RP (age-/sex adjusted (adj) HR 1.6 [9%%CI 1.4, 1.9]) than a FP (adjHR 1.3 [95% CI1.2, 1.5]) compared to stable patients (p&amp;lt;0.001, respectively). Overall, patients with AMI and a FP had the highest event rate (Figure). The PPV and the specificity to rule-in MI using both algorithms was significantly higher for patients with RP (0/1h: PPV 75.8 [70.3, 80.7], specificity; 72.3 [66.2, 77.9]; 0/3h: PPV 73.8 [69.9, 77.4], specificity 63.1 [58.1, 67.9]) compared to those with FP (0/1h: PPV 51.0 [42.7, 59.3], specificity 70.1 [63.9, 75.8]; 0/3h: PPV 57.0 [49.4, 64.3], specificity 74.0 [68.6, 78.9]). Conclusion Despite the known elevated risk of dynamic hs-cTnI changes (defining myocardial injury), patients with FP are at even greater risk for future events despite having fewer cardiovascular risk factors. The rule-in of MI using established and recommended stratification algorithms is worse in these patients, wherefore the equal treatment of a FP and RP should be questioned. Funding Acknowledgement Type of funding source: Other. Main funding source(s): German Center of Cardiovascular Research (DZHK), Abbott Diagnostics, Prevencio, Singulex, University Medical Center of the Johannes Gutenberg University of Mainz, BRAHMS Aktiengesellschaft

european heart journal

Characteristics and outcomes of patients with suspected acute myocardial infarction according to rising and falling patterns of high-sensitive cardiac troponin